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Toronto Notes 2019 Common Presenting Problems
Follow-Up
• assessandencourageadherencetopharmacologicalandnon-pharmacologicaltherapyateveryvisit • lifestylemodificationq3-6mo
• pharmacological
■ follow up q1-2mo until BP under target for 2 consecutive visits. q3-6mo once at target BP
■ follow up frequently for patients with symptomatic/severe HTN, antihypertensive drug intolerance,
target organ damage
• referralisindicatedforcasesofrefractoryHTN,suspectedsecondarycauses,orworseningrenalfailure • hospitalizationisindicatedformalignantHTN
Joint Pain
• seeRheumatology,RH3
History
• numberofjointsinvolved:monoarticular,oligoarticular,polyarticular
• patternofjointsinvolved:symmetricalvs.asymmetrical,largevs.smalljoints,axialskeleton • onset:acutevs.chronic(>6wk)
• morning stiffness (duration) vs. worse at end of day with activity
• PMHx
■ trauma, infection, medications (steroids, diuretics)
■ cormorbidities: DM, renal insufficiency (gout), psoriatic arthiritis, myeloma, osteoporosis, and OA ■ FHx of arthritis, autoimmune disease
• ROS: constitutional symptoms (neoplasm, septic arthropathy), myalgia, skin/eye/nail/hand changes, and GI/GU changes
Physical Exam
• vitals
• specificjointexamstoaffectedareas
• systemicfeatures(skin,nails,eyes,hands)
Investigations (Guided by the History and Physical Exam)
• general:CBCanddifferential,electrolytes,Cr
• acutephasereactants:ESR,CRP,ferritin,albumin,fibrinogen
• complement(C3,C4)
• urinalysistodetectdiseasecomplications(proteinuria,activesediment)
• serology(ANA,anti-dsDNA,HLA-B27,anti-Jo-1,anti-Sm,anti-La,anti-Ro,RhF,andanti-CCP,etc.) • synovialfluidanalysis(cellcount+differential,culture,Gramstain,microscopy)
• tissuecultures
• radiology(plainfilm,CT,MRI,U/S,bonedensitometry,angiography,bonescan)
Treatment
• tailortherapydependingonthespecificcause
• non-pharmacological:patienteducation,lifestylemodification,assisteddevices,physiotherapy,
occupational therapy
• pharmacological:analgesia(acetaminophen,NSAIDs),anti-inflammatory(DMARDs,steroids),
antibiotics
Low Back Pain
• seeOrthopedics,OR26
• seeCOREBackTool:
http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/Health_Professionals/CEP_ CoreBackTool_2016.pdf
Definition
• acute:<6wk
• subacute:6-12wk • chronic:>12wk
Epidemiology
• 5thmostcommonreasonforvisitingaphysician
• lifetimeprevalence:90%,andpeakprevalence:age45-60
• largestWSIBcategoryandmostcommoncauseofchronicdisabilityforindividuals<45yrold • 90%resolvein6wk,<5%becomechronic
Family Medicine FM37
Signs and Symptoms of Inflammatory Arthritis
WARM(S) Joints
Worse with rest, better with activity Awakening in the latter half of the night Redness around joint
Morning stiffness (>30 min)
Soft tissue swelling, erythema
Systemic Features
• Fever (SLE, infection)
• Rash (SLE, psoriatic arthritis)
• Nail abnormalities (psoriatic, reactive
arthritis)
• Uveitis (psoriatic, reactive arthritis,
ankylosing spondylitis)
• Myalgias (fibromyalgia, myopathy)
• Weakness (polymyositis, neuropathy) • GI symptoms (scleroderma, IBD)
• GU symptoms (reactive arthritis,
gonococcemia)
Red Flags
Bowel or bladder dysfunction Anesthesia (saddle)
Constitutional symptoms/malignancy Chronic disease
Paresthesias
Age >50 and mild trauma
IV drug use/Infection
Neuromotor deficits